The Form 1-800 Mcba 971 is a form that is used to apply for and receive benefits from the Department of Veterans Affairs. This form can be used to apply for a variety of different benefits, including compensation, pension, education assistance, and health care. The form can be submitted online or through the mail, and it must be completed in full before it can be processed. If you are looking to receive benefits from the Department of Veterans Affairs, the Form 1-800 Mcba 971 is your best option.
| Question | Answer |
|---|---|
| Form Name | Form 1 800 Mcba 971 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | 49CFR, Lienczewski, relisting, preemployment |
MICHIGAN CHARTER BOAT ASSOCIATION
2014 Application for Membership and Internet Directory Listing
Renew
Immediately!
Applications are due
no later than
12/31/2013
(check one) |
❏ Captain ❏ Mate |
(*required) |
(check one) ❏ New MCBA membership ❏ MCBA membership renewal |
MEMBER INFORMATION
INTERNET DIRECTORY LISTING
Name*_____________________________________________________________ Date* ________________ Check No.*__________________
Address* __________________________________________________ Business Name* ___________________________________________
City* __________________________________ State* ____ Zip* _________ Web Site: www. ________________________________________
SSN: (last four digits)
USCG License Reference No.* _____________________ Exp Date* ___________ Winter Phone* ____________________________________
Date of Birth* ______________
Vessel Documentation No. or State Registration No.* ____________________Vessel Inspected?* Yes:❏ No:❏ DNR:❏ USCG:❏
( S p e c i f y A g e n c y )
Designated Employer Representative: IF NOT SELF ________________________________________DER Phone*____________________
The above information is required by the USCG for your annual MIS report. *Captains/Mates required to fill in business name & DER: employer
Charter Category: ❏ Fishing ❏ River Fishing ❏ Cruise/Excursion ❏ Sailing ❏ Diving ❏ Captain For Hire ❏ Other____________
❏Check if new Home Port: ___________________________________❏ Lake/River ______________________________________________
Secondary Ports ($30.00 each; limit 3 per category. You must operate from the ports listed.)
1. ________________________________ |
2. _____________________________________ |
3._____________________________________ |
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Species: |
❏ Salmon |
❏ Steelhead |
❏ Brown |
❏ Lake Trout |
❏ Walleye |
❏ Perch |
❏ Bass |
❏ Muskie |
Boat Name ________________________________________________ Business Name___________________________________________
Boat Type or Brand_____________________________Boat Length ______ Boat DNR Inspected? Yes:❏ No:❏ USCG Inspected Yes:❏
Additional Charter Categories: $30 EACH ❏ Other:_____________________________________ Catch & Cook Member? Yes: ❏ No: ❏
(Example: “Captain For Hire”, “Cruise/Excursion”,"Fishing", “River Fishing”, "Sailboat Charters", & "Dive Charters" would be separate listings.)
Make copy of form and complete for each additional category; then submit with application and payment.
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❏ CAPTAIN: MCBA Membership, Internet Directory Listing and MCBA Drug Screening Program |
$145.00 |
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CATEGORIES |
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❏ CAPTAIN: MCBA Membership and MCBA Drug Screening Program |
$135.00 |
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❏ MATE: MCBA Associate Membership, Internet Directory Listing and MCBA Drug Screening Program |
$45.00 |
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❏ CAPTAIN: MCBA Membership and Internet Directory Listing (Must include Letter of Compliance from current drug screening Company) |
$135.00 |
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MEMBERSHIP |
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❏ |
.. $55.00 |
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❏ MCBA Scholarship Fund (Donation is tax deductible) |
$_____ |
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❏ MCBA Membership, Retired Captain (concluded their active membership) |
$30.00 |
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Membership $ _______ + ____ (Secondary Ports @ $30) + _____(Add’l Categories @ $30) +____ |
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TOTAL DUE |
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☛“Members not renewed by January 1, 2014 will be subject to a late fee for website removal and relisting”
Check appropriate box and sign
❏I am currently enrolled in the MCBA Drug Screening Program
❏I am currently enrolling in the MCBA Drug Screening Program
❏I am currently enrolled in another marine industry Drug Screening Program which has not lapsed. I am excluding myself from the pre- employment
❏Enclosed are the results of my
I certify that the information contained in this application is true.
__________________________________________________________
Signed |
Date |
Check Options: (provide me with the requested information)
❏Water Proof Boat Emergency Checklist
❏MCBA Logo Decal
❏Drug Program Zero Tolerance Decal
❏MCBA Bumper Sticker
Please make check payable and return to:
MCBA Membership
38000 Castle Drive
Romulus, MI 48174
(The information on this application is subject to change without notice) 9/13